patient is treated at a clinic with an injection of long-acting penicillin for a streptococcal throat infection. Her history reveals that she had received penicillin once
before with no allergic response. When the penicillin injection is administered, the nurse should inform the patient which of the following?
A) She must wait in the clinic area for 20 minutes before she is discharged
The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE?
C. The steroids will suppress tissue inflammation, which reduces damage to organs.
3. The main function of steroid medications is to suppress the inflammatory response of the body.
A patient arrives in the emergency department after being in a car crash with fatalities. The patient has a nearly amputated leg that is bleeding. What action by the
nurse takes priority?
A. Ensure the client has a patent airway
Rationale: Airway is the priority, followed by breathing and circulation (IVs and direct
pressure). Obtaining consent is done by the physician.
nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min
since they were last assessed 4 hours ago.
D. Assess the client's tissue perfusion further.
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.
The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
C. Client with a blood pressure change of 128/74 to 110/88 mm Hg
This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
D. Double checking the client and blood product identification
